ZAFEMY by is a Prescription medication manufactured, distributed, or labeled by Amneal Pharmaceuticals LLC, Amneal Pharmaceuticals, LLC. Drug facts, warnings, and ingredients follow.
Warnings and Precautions (5.12) 11/2021
ZAFEMY® is an estrogen/progestin combination hormonal contraceptive (CHC), indicated for the prevention of pregnancy in women with a BMI < 30 kg/m2 for whom a combined hormonal contraceptive is appropriate. (1)
Limitations of Use: ZAFEMY may be less effective in preventing pregnancy in women at or above 198 lbs (90 kg). (1, 4, 14)
Transdermal system: 150 mcg/day norelgestromin, USP and 35 mcg/day ethinyl estradiol, USP. (3)
The most frequent adverse reactions reported during clinical trials (≥ 5%) were breast symptoms, nausea/vomiting, headache, application site disorder, abdominal pain, dysmenorrhea, vaginal bleeding and menstrual disorders, and mood, affect and anxiety disorders. (6.1)
To report SUSPECTED ADVERSE REACTIONS, contact Amneal Pharmaceuticals at 1-877-835-5472 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
Drugs or herbal products that induce certain enzymes (for example CYP3A4) may decrease the effectiveness of CHCs or increase breakthrough bleeding. Counsel patients to use a back-up or alternative method of contraception when enzyme inducers are used with CHCs. (7.1)
See 17 for PATIENT COUNSELING INFORMATION and FDA-approved patient labeling.
Revised: 4/2022
Cigarette smoking increases the risk of serious cardiovascular events from hormonal contraceptive use. This risk increases with age, particularly in women over 35 years of age, and with the number of cigarettes smoked. For this reason, CHCs, including ZAFEMY, are contraindicated in women who are over 35 years of age and smoke [see Contraindications (4) and Warnings and Precautions (5.1)].
ZAFEMY is contraindicated in women with a BMI ≥ 30 kg/m2. The risk of VTE may be greater with ZAFEMY in women with a BMI > 30 kg/m2 compared to women with a lower BMI [see Contraindications (4) and Warnings and Precautions (5.1)].
ZAFEMY® is indicated for the prevention of pregnancy in women with a body mass index (BMI) < 30 kg/m2 for whom a combined hormonal contraceptive is appropriate.
Limitations of Use:
ZAFEMY may be less effective in preventing pregnancy in women who weigh 198 lbs (90 kg) or more. ZAFEMY is contraindicated for use in women with BMI ≥ 30 kg/m2 [see Contraindications (4), Warnings and Precautions (5.1) and Clinical Studies (14)].
To achieve maximum contraceptive effectiveness, ZAFEMY must be used exactly as directed.
Complete instructions to facilitate patient counseling on proper system usage may be found in the FDA-Approved Patient Labeling.
The ZAFEMY transdermal system uses a 28-day (four-week) cycle. A new patch is applied each week for three weeks (21 total days). Week Four is patch-free. Withdrawal bleeding is expected during this time.
Every new patch should be applied on the same day of the week. This day is known as the “Patch Change Day.” For example, if the first patch is applied on a Monday, all subsequent patches should be applied on a Monday. Only one patch should be worn at a time.
Do not cut, damage or alter the ZAFEMY patch in any way. If the ZAFEMY patch is cut, damaged or altered in size, contraceptive efficacy may be impaired.
On the day after Week Four ends, a new four-week cycle is started by applying a new patch. Under no circumstances should there be more than a seven-day patch-free interval between dosing cycles.
There are multiple options for starting the ZAFEMY patch, and the woman should choose the option that is most appropriate (see Table 1):
Table 1: Instructions for Administration
Starting ZAFEMY patch in women with no current use of hormonal contraception |
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The woman has two options for starting the patch and she should choose the option that is right for her: First Day Start
Sunday Start
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Switching from another contraceptive method |
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Oral combination hormonal contraception (oral CHC) |
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Transdermal system |
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Vaginal ring |
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Injection |
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Intrauterine system (IUS) |
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Implant |
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Progestin-only pill |
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Use after Childbirth
Start contraceptive therapy with ZAFEMY in women who elect not to breastfeed no sooner than 4 weeks after childbirth due to increased risk of thromboembolism. If a woman begins using ZAFEMY postpartum, and has not yet had a period, consider the possibility of ovulation and conception occurring prior to use of ZAFEMY, and instruct her to use an additional method of contraception, such as a condom and spermicide or diaphragm and spermicide, for the first seven days [see Warnings and Precautions (5.1) and Pregnancy (8.1)].
Use after Abortion or Miscarriage
After an abortion or miscarriage that occurs in the first trimester, ZAFEMY may be started immediately. An additional method of contraception is not needed if ZAFEMY is started immediately. If use of ZAFEMY is not started within 5 days following a first trimester abortion, the woman should follow the instructions for a woman starting ZAFEMY for the first time. In the meantime she should be advised to use a non-hormonal contraceptive method. Ovulation may occur within 10 days of an abortion or miscarriage.
Start ZAFEMY no earlier than 4 weeks after a second trimester abortion or miscarriage, due to the increased risk of thromboembolic disease [see Contraindications (4) and Warnings and Precautions (5.1)].
CHOOSING A PLACE ON THE BODY TO PUT THE PATCH
Before applying the patch:
HOW TO APPLY THE PATCH
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WHEN TO CHANGE THE ZAFEMY PATCH
WHAT IF THE PATCH BECOMES LOOSE OR FALLS OFF?
The patch must stick securely to the skin to work properly. If the ZAFEMY patch becomes partially or completely detached and remains detached, insufficient drug delivery occurs. The woman should not try to reapply a patch if it is no longer sticky, if it has become stuck to itself or another surface, or if it has other material stuck to it.
If a patch edge lifts up:
If the patch has been off or partially off:
IF THE WOMAN FORGETS TO CHANGE HER PATCH
Under no circumstances should there be more than a seven-day patch-free interval between cycles. If there are more than seven patch-free days, THE WOMAN MAY NOT BE PROTECTED FROM PREGNANCY and back-up contraception, such as a condom and spermicide or diaphragm and spermicide, must be used for seven days. As with combined oral contraceptives, the risk of ovulation increases with each day beyond the recommended drug-free period. If she has had intercourse during such an extended patch-free interval, consider the possibility of pregnancy.
Change Day Adjustment
If the woman wishes to change her Patch Change Day, she should complete her current cycle, removing the third ZAFEMY patch on the correct day. During the patch-free week, she may select an earlier Patch Day Change by applying a new ZAFEMY patch on the desired day. In no case should there be more than 7 consecutive patch-free days.
Breakthrough Bleeding or Spotting
In the event of unscheduled or breakthrough bleeding or spotting (bleeding that occurs on the days that ZAFEMY is worn), treatment should be continued. If unscheduled bleeding persists longer than a few cycles, consider causes other than ZAFEMY.
If the woman does not have scheduled or withdrawal bleeding (bleeding that should occur during the patch-free week), she should resume treatment on the next scheduled Change Day. If ZAFEMY has been used correctly, the absence of withdrawal bleeding is not necessarily an indication of pregnancy. Nevertheless, consider the possibility of pregnancy, especially if absence of withdrawal bleeding occurs in 2 consecutive cycles. Discontinue ZAFEMY if pregnancy is confirmed.
In Case of Skin Irritation
If patch use results in uncomfortable irritation, the patch may be removed and a new patch may be applied to a different location until the next Change Day. Only one patch should be worn at a time.
Additional Instructions for Dosing
Unscheduled bleeding, spotting, and amenorrhea are frequent reasons for patients discontinuing hormonal contraceptives. In case of breakthrough bleeding, as in all cases of irregular bleeding from the vagina, consider nonfunctional causes. In case of undiagnosed persistent or recurrent abnormal bleeding from the vagina, take adequate diagnostic measures to rule out pregnancy or malignancy. If pathology has been excluded, time or a change to another method of contraception may solve the problem.
Use of Hormonal Contraceptives in the Event of a Missed Menstrual Period
ZAFEMY is contraindicated in females who are known to have or develop the following conditions:
Arterial Events
The use of CHCs increases the risk of cardiovascular events and cerebrovascular events, such as myocardial infarction and stroke. The risk is greater among older women (> 35 years of age), smokers, and women with hypertension, dyslipidemia, diabetes, or obesity. ZAFEMY is contraindicated in women over 35 years of age who smoke [see Contraindications (4)]. Cigarette smoking increases the risk of serious cardiovascular events from CHC use. This risk increases with age, particularly in women over 35 years of age, and with the number of cigarettes smoked.
Venous Events
The use of CHCs increases the risk of venous thromboembolic events (VTEs), such as deep vein thrombosis and pulmonary embolism. Risk factors for VTEs include smoking, obesity, and family history of VTE, in addition to other factors that contraindicate use of CHCs. The risk of VTE may be greater with ZAFEMY in women with a BMI ≥ 30 kg/m2 compared to women with a lower BMI [see Contraindications (4)].
While the risk of VTE associated with the use of CHCs is well-established, the rates of VTE are even greater during pregnancy, and especially during the post-partum period (see Figure 1). The frequency of VTE in women using CHCs has been estimated to be 3 to 12 cases per 10,000 woman-years.
The risk of VTE is highest during the first year of use of CHCs and when restarting hormonal contraception after a break of 4 weeks or longer. This initial higher risk declines during the first year, but users of CHCs remain at an increased risk of VTE compared to non-users of CHCs. Based on results from a few studies, there is some evidence that this is true for non-oral products as well. The risk of thromboembolic disease due to CHCs gradually disappears after CHC use is discontinued.
Figure 1 shows the risk of developing a VTE for women who are not pregnant and do not use CHCs, for women who use CHCs with a range of doses and routes of administration, for pregnant women, and for women in the post-partum period. To put the risk of developing a VTE into perspective: If 10,000 women who are not pregnant and do not use CHCs are followed for one year, between 1 and 5 of these women will develop a VTE.
Figure 1: Likelihood of Developing a VTE Within One Year Among Pregnant and Non-Pregnant Women
*CHC = combination hormonal contraception
**Pregnancy data based on actual duration of pregnancy in the reference studies. Based on a model assumption that pregnancy duration is nine months, the rate is 7 to 27 per 10,000 WY.
Higher estrogen exposure may increase the risk of adverse reactions, including venous thromboembolism (VTE). The Area Under the Curve (AUC) for ethinyl estradiol (EE) is approximately 60% higher in women using ZAFEMY compared to oral contraceptives containing EE 35 mcg. In contrast, the peak concentration (Cmax) for EE is approximately 25% lower in women using ZAFEMY [see Clinical Pharmacology (12.3)].
Impaired Liver Function
Do not use ZAFEMY in women with liver disease, such as acute viral hepatitis or severe (decompensated) cirrhosis of liver [see Contraindications (4)]. Discontinue ZAFEMY if jaundice develops. Acute or chronic disturbances of liver function may necessitate the discontinuation of CHC use until markers of liver function return to normal and CHC causation has been excluded.
Liver Tumors
ZAFEMY is contraindicated in women with benign and malignant liver tumors [see Contraindications (4)]. Hepatic adenomas are associated with CHC use. An estimate of the attributable risk is 3.3 cases/100,000 CHC users. Rupture of hepatic adenomas may cause death through intra-abdominal hemorrhage.
Studies have shown an increased risk of developing hepatocellular carcinoma in long-term (>8 years) CHC users. However, the risk of liver cancers in CHC users is less than one case per million users.
During clinical trials with the Hepatitis C combination drug regimen that contains ombitasvir/paritaprevir/ritonavir, with or without dasabuvir, ALT elevations greater than 5 times the upper limit of normal (ULN), including some cases greater than 20 times the ULN, were significantly more frequent in women using ethinyl estradiol-containing medications, such as CHCs. Discontinue ZAFEMY prior to starting therapy with the combination drug regimen ombitasvir/paritaprevir/ritonavir, with or without dasabuvir [see Contraindications (4)]. ZAFEMY can be restarted approximately 2 weeks following completion of treatment with the Hepatitis C combination drug regimen.
ZAFEMY is contraindicated in women with uncontrolled hypertension or hypertension with vascular disease [see Contraindications (4)]. For women with well-controlled hypertension, monitor blood pressure and stop ZAFEMY if blood pressure rises significantly.
An increase in blood pressure has been reported in women taking hormonal contraceptives, and this increase is more likely in older women with extended duration of use. The incidence of hypertension increases with increasing concentrations of progestin.
Studies suggest a small increased relative risk of developing gallbladder disease among CHC users. Use of CHCs may also worsen existing gallbladder disease. A past history of CHC-related cholestasis predicts an increased risk with subsequent CHC use. Women with a history of pregnancy-related cholestasis may be at an increased risk for CHC-related cholestasis.
Carefully monitor prediabetic and diabetic women who take ZAFEMY. CHCs may decrease glucose tolerance in a dose-related fashion. In a 6-cycle clinical trial with ZAFEMY patch there were no clinically significant changes in fasting blood glucose from baseline to end of treatment.
Consider alternative contraception for women with uncontrolled dyslipidemia. A small proportion of women will have adverse lipid changes while on hormonal contraceptives.
Women with hypertriglyceridemia, or a family history thereof, may be at an increased risk of pancreatitis when using hormonal contraceptives.
If a woman taking ZAFEMY develops new headaches that are recurrent, persistent or severe, evaluate the cause and discontinue ZAFEMY if indicated.
Consider discontinuation of ZAFEMY in the case of increased frequency or severity of migraine during hormonal contraceptive use (which may be prodromal of a cerebrovascular event).
Unscheduled Bleeding and Spotting
Unscheduled (breakthrough) bleeding and spotting sometimes occur in women using ZAFEMY. Consider non-hormonal causes and take adequate diagnostic measures to rule out malignancy, other pathology, or pregnancy in the event of unscheduled bleeding, as in the case of any abnormal vaginal bleeding. If pathology and pregnancy have been excluded, time or a change to another contraceptive product may resolve the bleeding.
In the clinical trials, most women started their scheduled (withdrawal) bleeding on the fourth day of the drug-free interval, and the median duration of withdrawal bleeding was 5 to 6 days. On average, 26% of women per cycle had 7 or more total days of bleeding and/or spotting (this includes both scheduled and unscheduled bleeding and/or spotting). Three clinical studies of the efficacy of ZAFEMY in preventing pregnancy assessed scheduled and unscheduled bleeding [see Clinical Studies (14)] in 3,330 women who completed 22,155 cycles of exposure. A total of 36 (1.1%) of the women discontinued ZAFEMY at least in part, due to bleeding or spotting.
Table 2 summarizes the proportion of subjects who experienced unscheduled (breakthrough) bleeding/spotting by treatment cycle.
Table 2: Unscheduled (Breakthrough) Bleeding/Spotting (Subjects Evaluable for Efficacy) |
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Treatment Cycle |
Pooled data from 3 studies |
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n |
%a |
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Cycle 1 |
2,994 |
18.2 |
Cycle 2 |
2,743 |
11.9 |
Cycle 3 |
2,699 |
11.6 |
Cycle 4 |
2,541 |
10.1 |
Cycle 5 |
2,532 |
9.2 |
Cycle 6 |
2,494 |
8.3 |
Cycle 7 |
698 |
8.3 |
Cycle 8 |
692 |
8.7 |
Cycle 9 |
654 |
8.6 |
Cycle 10 |
621 |
8.7 |
Cycle 11 |
631 |
8.9 |
Cycle 12 |
617 |
6.3 |
Cycle 13 |
611 |
8.0 |
a Percentage of subjects with breakthrough bleeding/spotting events. |
Amenorrhea and Oligomenorrhea
In the event of amenorrhea, consider the possibility of pregnancy. If the patient has not adhered to the prescribed dosing schedule (missed one patch or started the patch on a day later than she should have), consider the possibility of pregnancy at the time of the first missed period and take appropriate diagnostic measures. If the patient has adhered to the prescribed regimen and misses two consecutive periods, rule out pregnancy.
Some women may encounter amenorrhea or oligomenorrhea after discontinuation of hormonal contraceptive use, especially when such a condition was pre-existent.
Extensive epidemiological studies have revealed no increased risk of birth defects in women who have used oral contraceptives prior to pregnancy. Studies also do not suggest a teratogenic effect, particularly in so far as cardiac anomalies and limb reduction defects are concerned, when oral contraceptives are taken inadvertently during early pregnancy. Discontinue ZAFEMY use if pregnancy is confirmed.
Administration of CHCs should not be used as a test for pregnancy [see Use in Specific Populations (8.1)].
Carefully observe women with a history of depression and discontinue ZAFEMY if depression recurs to a serious degree.
Breast Cancer
ZAFEMY is contraindicated in females who currently have or have had breast cancer because breast cancer may be hormonally sensitive [see Contraindications (4)]. Epidemiology studies have not found a consistent association between use of combined oral contraceptives (COCs) and breast cancer risk. Studies do not show an association between ever (current or past) use of COCs and risk of breast cancer. However, some studies report a small increase in the risk of breast cancer among current or recent users (<6 months since last use) and current users with longer duration of COC use [see Postmarketing Experience (6.2)].
Cervical Cancer
Some studies suggest that combination oral contraceptive use has been associated with an increase in the risk of cervical cancer or intraepithelial neoplasia. However, there continues to be controversy about the extent to which such findings may be due to differences in sexual behavior and other factors.
The estrogen component of CHCs may raise the serum concentrations of thyroxine-binding globulin, sex hormone-binding globulin and cortisol-binding globulin. The dose of replacement thyroid hormone or cortisol therapy may need to be increased.
A woman who is taking hormonal contraceptive should have routine visits with her healthcare provider for a blood pressure check and for other indicated healthcare.
The following serious adverse reactions with the use of combination hormonal contraceptives, including ZAFEMY, are discussed elsewhere in the labeling:
Adverse reactions commonly reported by users of combination hormonal contraceptives are:
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.
The data described below reflect exposure to ZAFEMY in 3,330 sexually active women (3,322 of whom had safety data) who participated in three Phase 3 clinical trials designed to evaluate contraceptive efficacy and safety. These subjects received six or 13 cycles of contraception (ZAFEMY or an oral contraceptive comparator in 2 of the trials). The women ranged in age from 18 to 45 years and were predominantly white (91%).
The most common adverse reactions (≥ 5%) reported during clinical trials were breast symptoms, nausea/vomiting, headache, application site disorder, abdominal pain, dysmenorrhea, vaginal bleeding and menstrual disorders, and mood, affect and anxiety disorders. The most common events leading to discontinuation were application site reaction, breast symptoms (including breast discomfort, engorgement and pain), nausea and/or vomiting, headache and emotional lability.
Adverse drug reactions reported by ≥ 2.5% of ZAFEMY-treated subjects in these trials are shown in Table 3.
Table 3: Adverse Drug Reactions Reported by ≥ 2.5% of ZAFEMY-treated Subjects in Three Phase 3 Clinical Trials |
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System/Organ Class* |
ZAFEMY |
Reproductive system and breast disorders | |
Breast symptoms† |
22.4% |
Dysmenorrhea |
7.8% |
Vaginal bleeding and menstrual disorders† |
6.4% |
Gastrointestinal disorders | |
Nausea |
16.6% |
Abdominal pain† |
8.1% |
Vomiting |
5.1% |
Diarrhea |
4.2% |
Nervous system disorders | |
Headache |
21.0% |
Dizziness |
3.3% |
Migraine |
2.7% |
General disorders and administration site conditions | |
Application site disorder† |
17.1% |
Fatigue |
2.6% |
Psychiatric disorders | |
Mood, affect and anxiety disorders† |
6.3% |
Skin and subcutaneous tissue disorders | |
Acne |
2.9% |
Pruritus |
2.5% |
Infections and infestations | |
Vaginal yeast infection† |
3.9% |
Investigations | |
Weight increased |
2.7% |
* MedDRA version 10.0 |
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† Represents a bundle of similar terms |
Additional adverse drug reactions that occurred in < 2.5% of ZAFEMY-treated subjects in the above clinical trials datasets are:
1Represents a bundle of similar terms
Five studies that compared breast cancer risk between ever-users (current or past use) of COCs and never-users of COCs reported no association between ever use of COCs and breast cancer risk, with effect estimates ranging from 0.90 to 1.12 (Figure 2).
Three studies compared breast cancer risk between current or recent COC users (<6 months since last use) and never users of COCs (Figure 2). One of these studies reported no association between breast cancer risk and COC use. The other two studies found an increased relative risk of 1.19 to 1.33 with current or recent use. Both of these studies found an increased risk of breast cancer with current use of longer duration, with relative risks ranging from 1.03 with less than one year of COC use to approximately 1.4 with more than 8 to 10 years of COC use.
Figure 2:
RR = relative risk; OR = odds ratio; HR = hazard ratio. “ever COC” are females with current or past COC use; “never COC use” are females that never used COCs.
The following adverse reactions (Table 4) have been identified during post-approval use of ZAFEMY. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
Table 4: Alphabetical List of Adverse Drug Reactions Identified During Postmarketing Experience with ZAFEMY by System Organ Class* |
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System Organ Class |
Adverse Drug Reactions |
Cardiac disorders |
Myocardial infarction† |
Endocrine disorders |
Hyperglycemia, insulin resistance |
Eye disorders |
Contact lens intolerance or complication |
Gastrointestinal disorders |
Colitis |
General disorders and administration site conditions |
Application site reaction†, edema† |
Hepatobiliary disorders |
Blood cholesterol abnormal, cholelithiasis, cholestasis, hepatic lesion, jaundice cholestatic, low density lipoprotein increased |
Immune system disorders |
Allergic reaction†, urticaria |
Investigations |
Blood glucose abnormal, blood glucose decreased |
Metabolism and nutrition disorders |
Increased appetite |
Neoplasms benign, malignant and unspecified (Incl. cysts and polyps) |
Breast cancer†, cervix carcinoma, hepatic adenoma, hepatic neoplasm |
Nervous system disorders |
Dysgeusia, migraine with aura |
Psychiatric disorders |
Anger, emotional disorder, frustration, irritability |
Reproductive system and breast disorders |
Breast mass, cervical dysplasia, fibroadenoma of breast, menstrual disorder†, suppressed lactation, uterine leiomyoma |
Skin and subcutaneous tissues disorders |
Alopecia, eczema, erythema multiforme, erythema nodosum, photosensitivity reaction, pruritus generalized, rash†, seborrheic dermatitis, skin reaction |
Vascular disorders |
Arterial thrombosis†, cerebrovascular accident†, deep vein thrombosis†, hemorrhage intracranial†, hypertension, hypertensive crisis, pulmonary embolism†, thrombosis† |
* MedDRA version 10.0 |
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† Represents a bundle of similar terms |
Consult the labeling of concurrently-used drugs to obtain further information about interactions with hormonal contraceptives or the potential for enzyme alterations.
Substances Decreasing the Plasma Concentrations of CHCs and Potentially Diminishing the Efficacy of CHCs:
Drugs or herbal products that induce certain enzymes, including cytochrome P450 3A4 (CYP3A4), may decrease the plasma concentrations of CHCs and potentially diminish the effectiveness of CHCs or increase breakthrough bleeding. Some drugs or herbal products that may decrease the effectiveness of hormonal contraceptives include phenytoin, barbiturates, carbamazepine, bosentan, felbamate, griseofulvin, oxcarbazepine, rifampicin, topiramate, rifabutin, rufinamide, aprepitant, and products containing St. John’s wort. Interactions between hormonal contraceptives and other drugs may lead to breakthrough bleeding and/or contraceptive failure. Counsel women to use an alternative method of contraception or a back-up method when enzyme inducers are used with CHCs, and to continue back-up contraception for 28 days after discontinuing the enzyme inducer to ensure contraceptive reliability.
Substances Increasing the Plasma Concentrations of CHCs:
Co-administration of atorvastatin or rosuvastatin and certain CHCs containing EE increase AUC values for EE by approximately 20% to 25%. Ascorbic acid and acetaminophen may increase plasma EE concentrations, possibly by inhibition of conjugation. CYP3A4 inhibitors such as itraconazole, voriconazole, fluconazole, grapefruit juice, or ketoconazole may increase plasma hormone concentrations.
Human Immunodeficiency Virus (HIV)/Hepatitis C Virus (HCV) Protease Inhibitors and Non-Nucleoside Reverse Transcriptase Inhibitors:
Significant changes (increase or decrease) in the plasma concentrations of estrogen and/or progestin have been noted in some cases of co-administration with HIV protease inhibitors (decrease [e.g., nelfinavir, ritonavir, darunavir/ritonavir, (fos)amprenavir/ritonavir, lopinavir/ritonavir, and tipranavir/ritonavir] or increase [e.g., indinavir and atazanavir/ritonavir])/HCV protease inhibitors or with non-nucleoside reverse transcriptase inhibitors (decrease [e.g., nevirapine] or increase [e.g., etravirine]).
CHCs containing EE may inhibit the metabolism of other compounds (e.g., cyclosporine, prednisolone, theophylline, tizanidine, and voriconazole) and increase their plasma concentrations. CHCs have been shown to decrease plasma concentrations of acetaminophen, clofibric acid, morphine, salicylic acid, and temazepam. Significant decrease in plasma concentration of lamotrigine has been shown, likely due to induction of lamotrigine glucuronidation. This may reduce seizure control; therefore, dosage adjustments of lamotrigine may be necessary.
Women on thyroid hormone replacement therapy may need increased doses of thyroid hormone because serum concentration of thyroid-binding globulin increases with use of CHCs [see Warnings and Precautions (5.13)].
Do not co-administer ZAFEMY with HCV drug combinations containing ombitasvir/paritaprevir/ritonavir, with or without dasabuvir, due to potential for ALT elevations [see Warnings and Precautions (5.4)].
There is little or no increased risk of birth defects in women who inadvertently use hormonal contraceptives during early pregnancy. Epidemiologic studies and meta-analyses have not found an increased risk of genital or non-genital birth defects (including cardiac anomalies and limb reduction defects) following exposure to low dose hormonal contraceptives prior to conception or during early pregnancy.
The administration of hormonal contraceptives to induce withdrawal bleeding should not be used as a test for pregnancy. Hormonal contraceptives should not be used during pregnancy to treat threatened or habitual abortion.
The effects of ZAFEMY in nursing mothers have not been evaluated and are unknown. When possible, advise the nursing mother to use other forms of contraception until she has completely weaned her child. Estrogen-containing CHCs can reduce milk production in breastfeeding mothers. This is less likely to occur once breastfeeding is well-established; however, it can occur at any time in some women. Small amounts of contraceptive steroids and/or metabolites are present in breast milk.
Safety and efficacy of ZAFEMY have been established in women of reproductive age. Efficacy is expected to be the same for post-pubertal adolescents under the age of 18 and for users 18 years and older. Use of this product before menarche is not indicated.
ZAFEMY has not been studied in postmenopausal women and is not indicated in this population.
No studies with ZAFEMY have been conducted in women with hepatic impairment. However, steroid hormones may be poorly metabolized in patients with impaired liver function. Acute or chronic disturbances of liver function may necessitate the discontinuation of combined hormonal contraceptive use until markers of liver function return to normal and combined hormonal contraceptive causation has been excluded [see Contraindications (4) and Warnings and Precautions (5.3)].
ZAFEMY is contraindicated in women with a BMI ≥ 30 kg/m2 because of the potential increased risk of VTE [see Contraindications (4) and Warnings and Precautions (5.1)].
ZAFEMY may be less effective in preventing pregnancy in women who weigh 198 lbs or more [see Clinical Studies (14)].
ZAFEMY is a transdermal system with a contact surface area of 12.5 cm2. It contains 3.15 mg norelgestromin, USP (NGMN) and 0.289 mg ethinyl estradiol, USP (EE), and its delivery rate is approximately 150 mcg of NGMN, USP and 35 mcg of EE, USP per day. Systemic exposures (as measured by area under the curve [AUC] and steady-state concentration [Css]) of NGMN, USP and EE, USP during use of ZAFEMY are higher and the Cmax is lower than those produced by an oral contraceptive containing norgestimate, USP (NGM) 250 mcg / EE, USP 35 mcg [see Boxed Warning and Clinical Pharmacology (12.3)].
ZAFEMY is a thin, matrix-type transdermal system consisting of three layers. The backing layer is composed of a tan backing consisting of pigmented polyethylene and polyester. It provides structural support and protects the middle adhesive layer from the environment. The middle layer contains polyisobutylene/polybutene adhesive, polybutene, crospovidone, oleyl alcohol and dipropylene glycol as inactive components. The active components in this layer are the hormones, NGMN, USP and EE, USP. The third layer is the release liner, which protects the adhesive layer during storage and is removed just prior to application. It is a transparent polyethylene terephthalate (PET) film with a silicone coating on the side that is in contact with the middle adhesive layer.
The outside of the backing layer is printed with “Norelgestromin and Ethinyl Estradiol 150/35 mcg per day” in brown ink.
The structural formulas of the components are:
Norelgestromin, USP ethinyl estradiol, USP
Molecular weight, NGMN, USP: 327.47
Molecular weight, EE, USP: 296.41
Chemical name for NGMN, USP: 18, 19-Dinorpregn-4-en-20-yn-3-one, 13-ethyl-17-hydroxy-,3-oxime,(17α)
Chemical name for EE, USP: 19-Norpregna-1,3,5(10)-trien-20-yne-3, 17-diol,(17α)
NGMN is the active progestin largely responsible for the progestational activity that occurs in women following application of ZAFEMY. NGMN is also the primary active metabolite produced following oral administration of NGM, the progestin component of some oral contraceptive products.
Combination hormonal contraceptives act by suppression of gonadotropins. Although the primary mechanism of this action is inhibition of ovulation, other alterations include changes in the cervical mucus (which increase the difficulty of sperm entry into the uterus) and the endometrium (which reduce the likelihood of implantation).
One clinical trial assessed the return of hypothalamic-pituitary-ovarian axis function post-therapy and found that follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol mean values, though suppressed during therapy, returned to near baseline values during the 6 weeks post therapy.
Absorption
The systemic delivery rate of NGMN and EE from ZAFEMY is approximately 150 mcg of NGMN and 35 mcg of EE per day based on a comparative analysis with intravenous (IV) data. Following a single application of ZAFEMY, both NGMN and EE reach a plateau by approximately 48 hours. Pooled data from the 3 clinical studies have demonstrated that steady-state is reached within 2 weeks of application. In one of the clinical studies, Css concentrations across all subjects ranged from 0.305 to 1.53 ng/mL for NGMN and from 23 to 137 pg/mL for EE.
Absorption of NGMN and EE following application of ZAFEMY to the buttock, upper outer arm, abdomen and upper torso (excluding breast) was examined. While absorption from the abdomen was slightly lower than from other sites, absorption from these anatomic sites was considered to be therapeutically equivalent.
The mean (%CV) PK parameters Css and AUC0-168 for NGMN and EE following a single buttock application of ZAFEMY are summarized in Table 5.
In multiple dose studies, AUC0-168 for NGMN and EE was found to increase over time (Table 5). In a three-cycle study, these PK parameters reached steady-state conditions during Cycle 3 (Figures 5 and 4). Upon removal of the patch, serum levels of EE and NGMN reach very low or non-measurable levels within 3 days.
Table 5: Mean (%CV*) PK Parameters of NGMN and EE Following 3 Consecutive Cycles of ZAFEMY Wear on the Buttock |
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Analyte |
Parameter |
Cycle 1 |
Cycle 3 |
Cycle 3 |
Cycle 3 |
NGMN |
Css (ng/mL)
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0.70 (39.4) |
0.70 (41.8) |
0.80 (28.7) |
0.70 (45.3) |
EE |
Css (pg/mL)
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46.4 (38.5) |
47.6 (36.4) |
59.0 (42.5) |
49.6 (54.4) |
nc = not calculated, *%CV is % of Coefficient of variation = 100 (standard deviation/mean) |
Figure 3: Mean Serum NGMN Concentrations (ng/mL) in Healthy Female Volunteers Following Application of ZAFEMY on the Buttock for Three Consecutive Cycles (Vertical arrow indicates time of patch removal)
Figure 4: Mean Serum EE Concentrations (pg/mL) in Healthy Female Volunteers Following Application of ZAFEMY on the Buttock for Three Consecutive Cycles (Vertical arrow indicates time of patch removal.)
The absorption of NGMN and EE following application of ZAFEMY was studied under conditions encountered in a health club (sauna, whirlpool and treadmill) and in a cold water bath.
The results indicated that for NGMN, there were no significant treatment effects on Css or AUC when compared to normal wear. For EE, increased exposures were observed due to sauna, whirlpool and treadmill. There was no significant effect of cold water on these parameters.
Results from a study of consecutive ZAFEMY wear for 7 days and 10 days indicated that serum concentrations of NGMN and EE dropped slightly during the first 6 hours after the patch replacement, and recovered within 12 hours. By Day 10 of patch administration, both NGMN and EE concentrations had decreased by approximately 25% when compared to Day 7 concentrations.
Metabolism
Since norelgestromin and ethinyl estradiol are delivered transdermally, first-pass metabolism (via the gastrointestinal tract and/or liver) of NGMN and EE that would be expected with oral administration does not occur. Hepatic metabolism of NGMN occurs and metabolites include norgestrel, which is highly bound to SHBG, and various hydroxylated and conjugated metabolites. EE is also metabolized to various hydroxylated products and their glucuronide and sulfate conjugates.
Distribution
NGMN and norgestrel (a serum metabolite of NGMN) are highly bound (>97%) to serum proteins. NGMN is bound to albumin and not to SHBG, while norgestrel is bound primarily to SHBG, which limits its biological activity. EE is extensively bound to serum albumin and induces an increase in the serum concentrations of SHBG (see Table 5).
Elimination
Following removal of patches, the elimination kinetics of NGMN and EE were consistent for all studies with half-life values of approximately 28 hours and 17 hours, respectively. The metabolites of NGMN and EE are eliminated by renal and fecal pathways.
Transdermal versus Oral Contraceptives
The ZAFEMY transdermal patch delivers EE and NGMN over a seven-day period while oral contraceptives (containing NGM 250 mcg / EE 35 mcg) are administered on a daily basis. Figures 5 and 6 present mean PK profiles for EE and NGMN following administration of an oral contraceptive (containing NGM 250 mcg / EE 35 mcg) compared to the 7-day transdermal ZAFEMY patch (containing NGMN 3.15 mg / EE 0.289 mg) during Cycle 2 in 32 healthy female volunteers.
Figure 5: Mean Serum Concentration-Time Profiles of NGMN Following Once-Daily Administration of an Oral Contraceptive for 2 Cycles or Application of ZAFEMY for 2 Cycles to the Buttock in Healthy Female Volunteers. [Oral contraceptive: Cycle 2, Days 15 to 21, ZAFEMY: Cycle 2, Week 3]
Figure 6: Mean Serum Concentration-Time Profiles of EE Following Once-Daily Administration of an Oral Contraceptive for 2 Cycles or Application of ZAFEMY for 2 Cycles to the Buttock in Healthy Female Volunteers. [Oral contraceptive: Cycle 2, Days 15 to 21, ZAFEMY: Cycle 2, Week 3]
Table 6 provides the mean (%CV) for NGMN and EE pharmacokinetic (PK) parameters.
Table 6: Mean (%CV) NGMN and EE Steady-State Pharmacokinetic Parameters Following Application of ZAFEMY and Once-Daily Administration of an Oral Contraceptive (containing NGM 250 mcg / EE 35 mcg) in Healthy Female Volunteers |
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Parameter |
ZAFEMY* |
ORAL CONTRACEPTIVE† |
NGMN‡ | ||
Cmax (ng/mL) |
1.12 (33.6) |
2.16 (25.2) |
AUC0-168 (ng·h/mL) |
145 (36.8) |
123 (30.2)§ |
Css (ng/mL) |
0.888 (36.6) |
0.732 (30.2)¶ |
EE | ||
Cmax (pg/mL) |
97.4 (31.6) |
133 (27.7) |
AUC0-168 (pg·h/mL) |
12,971 (33.1) |
8,281 (26.9)§ |
Css (pg/mL) |
80.0 (33.5) |
49.3 (26.9)¶ |
* Cycle 2, Week 3 |
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† Cycle 2, Day 21 |
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‡ NGM is rapidly metabolized to NGMN following oral administration |
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§ Average weekly exposure, calculated as AUC24 × 7 |
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¶ Cavg |
In general, overall exposure for NGMN and EE (AUC and Css) was higher in subjects treated with ZAFEMY for both Cycle 1 and Cycle 2, compared to that for the oral contraceptive, while Cmax values were higher in subjects administered the oral contraceptive. Under steady-state conditions, AUC0-168 and Css for EE were approximately 55% and 60% higher, respectively, for the transdermal patch, and the Cmax was about 35% higher for the oral contraceptive, respectively. Inter-subject variability (%CV) for the PK parameters following delivery from ZAFEMY was higher relative to the variability determined from the oral contraceptive. The mean PK profiles are different between the two products and caution should be exercised when making a direct comparison of these PK parameters.
In Table 7, percent change in concentrations (%CV) of markers of systemic estrogenic activity (Sex Hormone Binding Globulin [SHBG] and Corticosteroid Binding Globulin [CBG]) from Cycle 1 Day 1 to Cycle 1 Day 22 is presented. Percent change in SHBG concentrations was higher for ZAFEMY users compared to women taking the oral contraceptive; percent change in CBG concentrations was similar for ZAFEMY and oral contraceptive users. Within each group, the absolute values for SHBG were similar for Cycle 1, Day 22 and Cycle 2, Day 22.
Table 7: Mean Percent Change (%CV) in SHBG and CBG Concentrations Following Once-Daily Administration of an Oral Contraceptive (containing NGM 250 mcg / EE 35 mcg) for One Cycle and Application of ZAFEMY for One Cycle in Healthy Female Volunteers | ||
Parameter | ZAFEMY (% change from Day 1 to Day 22) | ORAL CONTRACEPTIVE (% change from Day 1 to Day 22) |
SHBG | 334 (39.3) | 200 (43.2) |
CBG | 153 (40.2) | 157 (33.4) |
Drug Interactions
In a PK drug interaction study, oral administration of tetracycline HCl, 500 mg four times daily for 3 days prior to and 7 days during wear of ZAFEMY did not significantly affect the PK of NGMN or EE.
Use in Specific Populations
Effects of Age, Body Weight, Body Surface Area and Race
The effects of age, body weight, body surface area and race on the PK of NGMN and EE were evaluated in 230 healthy women from nine pharmacokinetic studies of single 7-day applications of ZAFEMY. For both NGMN and EE, increasing age, body weight and body surface area each were associated with slight decreases in Css and AUC values. However, only a small fraction (10% to 25%) of the overall variability in the PK of NGMN and EE following application of ZAFEMY may be associated with any or all of the above demographic parameters. There was no significant effect of race with respect to Caucasians, Hispanics and Blacks.
See Warnings and Precautions (5.3, 5.12) and Use in Specific Populations (8.1).
Norelgestromin was tested in in vitro mutagenicity assays (bacterial plate incorporation mutation assay, CHO/HGPRT mutation assay, chromosomal aberration assay using cultured human peripheral lymphocytes) and in one in vivo test (rat micronucleus assay) and found to have no genotoxic potential.
In 3 large clinical trials lasting 12 months, in North America, Europe and South Africa, 3,330 women (ages 18 to 45) completed 22,155 cycles of ZAFEMY patch use, the pregnancy rate in women aged 18 to 35 years was 1.07 (95% confidence interval 0.60, 1.76) per 100 woman-years of ZAFEMY patch use. The racial distribution was 91% Caucasian, 4.9% Black, 1.6% Asian, and 2.4% Other.
With respect to weight, 5 of the 15 pregnancies reported with ZAFEMY patch use were among women with a baseline body weight ≥ 198 lbs., which constituted < 3% of the study population. The greater proportion of pregnancies among women at or above 198 lbs. was statistically significant and suggests that ZAFEMY patch may be less effective in these women.
Patch Adhesion
In the clinical trials with ZAFEMY patch, approximately 2% of the cumulative number of patches completely detached and 3% partially detached. The proportion of subjects with at least 1 patch that completely detached ranged from 2% to 6%, with a reduction from Cycle 1 (6%) to Cycle 13 (2%). For instructions on how to manage detachment of patches, refer to Dosage and Administration (2).
ZAFEMY (norelgestromin and ethinyl estradiol transdermal system) is available in one strength of 150 mcg/day NGMN, USP and 35 mcg/day EE, USP.
ZAFEMY is a 12.5 cm2 system with rounded corners with tan backing printed with “Norelgestromin and Ethinyl Estradiol 150/35 mcg per day” in brown ink, protected with a removable translucent oversized dimple slit-release liner. Each patch contains 3.15 mg of norelgestromin, USP and 0.289 mg of ethinyl estradiol, USP.
Each transdermal system is packaged in a protective pouch.
ZAFEMY is available in folding cartons of 1 cycle each (NDC: 65162-358-03); each cycle contains 3 systems.
Store at 20° to 25°C (68° to 77°F); excursions permitted between 15° to 30°C (59° to 86°F) [see USP Controlled Room Temperature].
Store patches in their protective pouches. Apply immediately upon removal from the protective pouch.
Do not store in the refrigerator or freezer.
Used patches still contain some active hormones. The sticky sides of the patch should be folded together and the folded patch placed in a sturdy container, preferably with a child-resistant cap, and the container thrown in the trash. Used patches should not be flushed down the toilet.
See FDA-approved patient labeling (Patient Information and Instructions for Use)
Counsel patients about the following information:
All trademarks are the property of their respective owners.
Distributed by:
Amneal Pharmaceuticals LLC
Bridgewater, NJ 08807
Rev. 04-2022-04
ZAFEMY® (za feʹ my)
(norelgestromin and ethinyl estradiol transdermal system)
What is the most important information I should know about ZAFEMY?
Do not use ZAFEMY if you smoke cigarettes and are over 35 years old. Smoking increases your risk of serious cardiovascular side effects from hormonal birth control methods, including death from heart attack, blood clots or stroke. This risk increases with age and the number of cigarettes you smoke.
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Hormonal birth control methods help to lower the chances of becoming pregnant. They do not protect against HIV infection (AIDS) and other sexually transmitted infections. |
What is ZAFEMY? ZAFEMY is a birth control patch for women with a BMI less than 30 kg/m2. It contains two female hormones, an estrogen called ethinyl estradiol, and a progestin called norelgestromin. Hormones from ZAFEMY get into the blood stream and are processed by the body differently than hormones from birth control pills. You will be exposed to about 60% more estrogen if you use ZAFEMY than if you use a typical birth control pill containing 35 micrograms of estrogen. In general, increased estrogen may increase the risk of side effects. |
How well does ZAFEMY work? Your chance of getting pregnant depends on how well you follow the directions for using ZAFEMY. The better you follow the directions, the less chance you have of getting pregnant.
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Do not use ZAFEMY if you:
Hormonal birth control methods may not be a good choice for you if you have ever had jaundice (yellowing of the skin or eyes) caused by pregnancy or related to previous use of hormonal birth control. Tell your healthcare provider if you have ever had any of the above conditions. Your healthcare provider may recommend another method of birth control. |
Before you use ZAFEMY, tell your healthcare provider:
Tell your healthcare provider about all medicines and herbal products that you take. Some medicines and herbal products may make hormonal birth control less effective, including, but not limited to:
Use another birth control method (such as a condom and spermicide or diaphragm and spermicide) when you take medicines that may make the ZAFEMY patch less effective. Some medicines and grapefruit juice may increase your level of the hormone ethinyl estradiol if used together, including:
Hormonal birth control methods may interact with lamotrigine, an anti-seizure medicine used for epilepsy. This may increase the risk of seizures, so your healthcare provider may need to adjust the dose of lamotrigine. Women on thyroid replacement therapy may need increased doses of thyroid hormone. Know the medicines you take. Keep a list of them to show your doctor and pharmacist when you get a new medicine. |
How should I use ZAFEMY?
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What are the possible side effects of ZAFEMY?
See "What is the most important information I should know about ZAFEMY?"
ZAFEMY may cause serious side effects, including:
It is possible to die or be permanently disabled from a problem caused by a blood clot, such as a heart attack or a stroke. Some examples of serious blood clots are blood clots in the:
To put the risk of developing a blood clot into perspective: If 10,000 women who are not pregnant and do not use hormonal birth control are followed for one year, between 1 and 5 of these women will develop a blood clot. The figure below shows the likelihood of developing a serious blood clot for women who are not pregnant and do not use hormonal birth control, for women who use hormonal birth control, for pregnant women, and for women in the first 12 weeks after delivering a baby.
*CHC=combination hormonal contraception **Pregnancy data based on actual duration of pregnancy in the reference studies. Based on a model assumption that pregnancy duration is nine months, the rate is 7 to 27 per 10,000 WY. Call your healthcare provider right away if you have:
Other serious risks include
Some women have spotting or light bleeding, breast tenderness, or feel sick to their stomach during ZAFEMY use. If these symptoms occur, do not stop using the ZAFEMY patch. The problem will usually go away. If it doesn't go away, check with your healthcare provider. Less common side effects are:
Tell your healthcare provider about any side effect that bothers you or that does not go away.
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How should I store and throw away used ZAFEMY patches?
Keep ZAFEMY and all medicines out of the reach of children.
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General information about the safe and effective use of ZAFEMY Medicines are sometimes prescribed for purposes other than those listed in Patient Information. Do not use ZAFEMY for a condition for which it was not prescribed. Do not give ZAFEMY to other people, even if they have the same symptoms that you have. It may harm them.
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What are the ingredients in ZAFEMY?
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Does hormonal birth control cause cancer? It is not known if hormonal birth control causes breast cancer. Some studies, but not all, suggest that there could be a slight increase in the risk of breast cancer among current users with longer duration of use.
What should I know about my period when using ZAFEMY? When you use ZAFEMY you may have bleeding and spotting between periods, called unplanned bleeding. Unplanned bleeding may vary from slight staining between menstrual periods to breakthrough bleeding which is a flow much like a regular period. Unplanned bleeding occurs most often during the first few months of ZAFEMY use, but may also occur after you have been using the patch for some time. Such bleeding may be temporary and usually does not indicate any serious problems. It is important to continue using the patch on schedule. If the unplanned bleeding or spotting is heavy or lasts for more than a few days, you should discuss this with your healthcare provider.
Some women miss periods on hormonal birth control, even when they are not pregnant. However, if you go 2 or more months in a row without a period, or you miss your period after a month where you did not use all of your patches correctly, or you have symptoms associated with pregnancy, such as morning sickness or unusual breast tenderness, call your healthcare provider because you may be pregnant. Stop taking ZAFEMY if you are pregnant.
You may stop using ZAFEMY whenever you wish. Consider a visit with your healthcare provider for a pre-pregnancy checkup before you stop using the patch.
Amneal Pharmaceuticals LLC Bridgewater, NJ 08807 |
ZAFEMY® (za feʹ my)
(norelgestromin and ethinyl estradiol transdermal system)
ZAFEMY is for skin use only.
Do not cut, damage, or alter the ZAFEMY patch in any way.
How to start using your ZAFEMY patch:
Figure A
Figure B is a picture of the ZAFEMY patch.
Figure B
Step 1. Choose a place on your body for your ZAFEMY patch
Step 2: Apply your ZAFEMY patch
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Step 3: Throwing away your ZAFEMY patch
Important notes:
This Patient Information and Instructions for Use have been approved by the U.S. Food and Drug Administration.
Distributed by:
Amneal Pharmaceuticals LLC
Bridgewater, NJ 08807
Rev. 04-2022-04
ZAFEMY
norelgestromin and ethinyl estradiol patch |
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Labeler - Amneal Pharmaceuticals LLC (123797875) |
Establishment | |||
Name | Address | ID/FEI | Business Operations |
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Amneal Pharmaceuticals, LLC | 053542455 | analysis(65162-358) , label(65162-358) , manufacture(65162-358) , pack(65162-358) |
Mark Image Registration | Serial | Company Trademark Application Date |
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ZAFEMY 88769372 not registered Live/Pending |
Amneal Pharmaceuticals LLC 2020-01-22 |